Provider Demographics
NPI:1508145988
Name:VILLANUEVA, MICHAEL DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859
Mailing Address - Street 2:DEPT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:409-772-1211
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-2437
Practice Address - Country:US
Practice Address - Phone:409-772-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN604391163W00000X
TXAP121761367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN604391OtherSTATE MEDICAL LICENSE